Limp in Children : diagnostic strategy

Probability diagnosis

• post trauma/intense exercise causing strain syndromes
• ill fitting shoes
• Hip disorders, esp. transient synovitis
• Heel disorders (12-14 years)

Serious disorders not to be missed

• A. Toddlers
• DDH
• Child abuse
• Septic arthritis
• Foreign body (e.g. needle in foot)
• 4-8 years
• Perth's disorder
• Transient synovitis
• Adolescents
• SCFE
• Avulsion injuries (e.g. ischial tuberosity)
• Osteochondritis dissecans of knee
• Duchenne muscular dystrophy
• All groups
• Septic infections
• septic arthritis
• osteomyelitis
• tuberculosis
• Tumour
• Juvenile chronic arthritis
• Spinal disorders
• discitis
• fracture
• Pitfalls
• Foreign body 
• Osteochonndritis (aseptic necrosis)
• femoral head - Perthes' disorder
• knee - osgood-schlatter disorder
• calcaneum - sever disorder
• navicular - kohler disorder
• Myalgia 
• growing pains
• Overuse syndrome 
• patellar tendonopathy 
• Stress fracture
• Paget's disease 

Approach to pain in the arm and hand

Pain in the arm and hand: diagnostic strategy model

Probabiligy diagnosis

• Dysfunction of the cervical spine 
• Disorders of the shoulder
• Medial or lateral epicondylitis
• Overuse tendonitis of the wrist
• Carpal tunnel syndrome 
• Osteoarthritis of the thumb and DIP joints

Serious disorders not to be missed

• Cardiovascular 
• angina
• myocardial infarction 
• axillary vein thrombosis
• Neoplasia
• pancoast tumour
• bone tumours
• Severe infections
• septic arthritis (shoulder/elbow)
• osteomyelitis
• infections of tendon sheath and fascial spaces of hand 

Pitfalls (often missed)

• Entrapment neuropathies
• Pulled elbow 
• Foreign body 
• Rarities
• polymyalgia rheumatica
• Reflex sympathetic dystrophy
• Thoracic outlet syndrom e
• Arm claudication 
• kienbock disorder

Achilles tendonosis

Key features:

- Often gradual and insidious onset.

- Diagnosis is mainly made via history and examination. Imaging is not indicated in most cases, however, if there are atypical features such as sudden onset and significant swelling. U/S may be appropriate

- U/S features of tendonosis: neb-vascularity and fusiform thickening

- X-ray is indicated when: insertional tenderness or posterior impingement

- Pathophysiology of tendonosis is not fully understood. May be related to overtraining.

- Management:

• Rest (may need to be off sports for 4 - 6 weeks)
• Gradual return to activities
• Eccentric exercise program (12 weeks, 3 sets, 15 reps of slow heel drop)
• NSAIDs
• Autologous blood injection and platelet rich plasma injection 
• GTN patch + eccentric exercise